Financial incentives considered for the deceased

It may depend on the type, degree of incentive

To many who observe the organ transplant arena, it's both a simple and yet complex reckoning of supply and demand. Simple, in that supply and demand is the bedrock rule for economics. Complex, in that it forces the players in the organ transplant system in the U.S. to think about how one could meld health care with market forces in a way that achieves fairness to both the organ recipient and the organ donor.

Mary Ann Baily, PhD, is an economist and former research scholar at The Hastings Center in Garrison, NY, and also served in 2005-2006 on an Institute of Medicine committee of thought leaders in medical ethics who developed the IOM report: Organ Donation: Opportunities for Action in 2006.

When discussing the possibility of financial incentives for donors, she concludes that the problem isn't a question necessarily of appropriate and fair financial incentives, but the lack of supply that would exist regardless of the incentives offered.

"From the deceased donor point of view, it's a bit technical, because the point is that everyone is so sure that if you just offered money — that the real problem is people don't agree to donate their organs after they die — if you would just offer somebody money, those organs would be freed up, and suddenly you would eliminate the waiting list," Baily tells Medical Ethics Advisor.

"That's not true, because the problem isn't so much that people are unwilling to donate," she says. "It has much more to do with the process by which you obtain organs and who you can get them from."

Those deceased individuals who can donate organs are limited.

"Typically, the classic source of donor organs is people who are declared brain dead," Baily says. "Now, of the millions of people who die in the United States, very few die in circumstances where they are on mechanical support. Those are the only kind of people historically from whom you could get the organs. There are not that many."

According to the UNOS web site, as of Dec. 21, 2009, there were 105,451 recipients on U.S. waiting lists, and 10,916 organ donors from January through September 2009.

Baily maintains that this and the complex process involved in getting a donor organ to a recipient is a tremendous hurdle that limits the number of recipients who get organs for transplant. Then there is another matter of how many solid organs transplant centers can retrieve from each willing donor, with five being the traditional maximum.

"In order to get those organs, you have to have in place a very elaborate system of identifying [potential organ donors], ideally before they die, or while they're brain dead, and you have to mobilize the organ retrieval [system] — and those people have to be told, 'Be ready to take the organs,'" Baily explains.

"Who would you pay?"

Offering financial payments for organs could actually have the opposite of the desired effect: It could decrease willing donors.

Organ donation historically has rested on altruism, i.e., that an organ is a gift.

"Some people would be very put off by the payment, and other people might be offended [by the practice of payment] and not donate," she says.

Also, the amount paid would have to be high.

"Most ordinary people would [then] say, 'Now, wait a minute, we could use the money, too. And if it is the federal government paying for it, why shouldn't we get it, too," she notes.

New York City transplant surgeon Thomas Diflo, MD, FACS, suggests that some degree of financial incentives for deceased donors "is probably not a bad idea."

While it might improve the organ supply slightly, Diflo tells MEA "it wouldn't improve things enough that we would [eliminate] all the people on the [organ] waiting lists."

"I think the details have to be worked out, you know, funeral expenses — or some people have recommended tax breaks," he says. "….[B]ut I think maybe the details could be worked out, and I would not object to some sort of small type of incentive for the donors and the donor families."

Financial incentives for health care workers

Regardless of whether the organ donor is a deceased or living donor, Baily believes that those who work in the transplant health care arena also should receive, if not necessarily financial incentives for their work, then the necessary resources and motivation to participate in the system.

She notes that the clinicians who work in hospitals and in intensive care units are very busy and may feel overwhelmed when faced with the organ retrieval/donation process.

"Let me put it this way: I think a hospital should realize that they don't lose money by doing this," she says. "Hospitals are under a lot of financial pressure, and it's important that they [send] the right signals. I think it's dangerous to argue that hospitals do and should totally focus on financial incentives and never do anything good for the patient unless they're definitely not going to lose by it. It's up to them to be professional, and sometimes that means making decisions that are not necessarily profitable," she says.

Sources

  • Mary Ann Baily, PhD, former research scholar at The Hastings Center, Garrison, NY.
  • Thomas Diflo, MD, FACS, Associate Professor of Surgery; Director, Surgical Skills Lab, Chairman, NYU Institutional Review Board. NYU School of Medicine, New York City. E-mail: Thomas.diflo@nyumc.org.